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The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)

Observe for signs of respiratory distress and monitor oxygenation by pulse oximetry.

Keep infant in warmer with bilirubin lights to maintain temperature of 97.6° F (36.4° C).

Monitor temperature.

Continue to monitor glucose levels.

Explain to the mother that the baby’s respiratory rate needs to be below 60 breaths/minute to be able to breastfeed.

Tell the mother that she will need to discuss any concerns with the neonatologist.

Inform the mother that the baby is stable enough to take out of the warmer and bilirubin lights.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale

Monitoring for respiratory distress and checking oxygenation by pulse oximetry are critical in newborns, as they can indicate hypoxemia or respiratory issues requiring prompt intervention.

Choice B rationale

Maintaining the infant's temperature at 97.6°F (36.4°C) using a warmer and bilirubin lights is essential for thermoregulation and treating jaundice, ensuring proper physiological stability.

Choice C rationale

Regular temperature monitoring is vital to detect any signs of hypothermia or hyperthermia, which can indicate underlying health issues and guide appropriate interventions for the newborn.

Choice D rationale

Continued monitoring of glucose levels is crucial for detecting hypoglycemia, a common condition in newborns that can lead to seizures, brain damage, or other severe complications if left untreated.

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Correct Answer is B

Explanation

Choice A rationale

Starting IV fluids is essential but not the priority in this situation. Caffeine intake may alter anesthesia effects, and the anesthesiologist needs to be informed first.

Choice B rationale

Informing the anesthesia care provider is crucial because caffeine can affect anesthesia administration and increase the risk of complications, such as increased gastric acidity and delayed gastric emptying.

Choice C rationale

Ensuring preoperative lab results is important, but it is not the immediate priority compared to informing the anesthesia care provider about the caffeine intake, which directly impacts anesthesia management.

Choice D rationale

Contacting the obstetrician is necessary but secondary. The immediate priority is to inform the anesthesia care provider about the caffeine intake, which has direct implications for anesthesia and surgical safety.

A. Color of amniotic fluid. B. Maternal temperature. C. Deep tendon reflexes. D. Maternal blood pressure.

Correct Answer is B

Explanation

Choice A rationale

Monitoring the color of amniotic fluid is crucial for assessing fetal well-being, but it is not the primary concern in the case of prolonged ROM. The focus should be on preventing maternal and fetal infection.

Choice B rationale

Maternal temperature should be monitored more frequently because prolonged ROM increases the risk of infection, particularly chorioamnionitis. Early detection of fever can prompt timely intervention to prevent complications.

Choice C rationale

Deep tendon reflexes are not directly affected by prolonged ROM. Monitoring them is more relevant for conditions like preeclampsia, where neurological assessment is critical. It is not the main concern in this scenario.

Choice D rationale

Maternal blood pressure is important to monitor but is not the primary focus in the context of prolonged ROM. The main concern is the increased risk of infection, necessitating closer monitoring of maternal temperature.

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The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

At 0600, while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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